Return Completed Form to Azcim at Least Two Weeks Prior to Your Appointment Via Fax Or Mail

Patient Intake Form

Return Completed Form to AzCIM at least two weeks prior to your appointment via Fax or Mail:

FAX: MAIL: Attn: Dr. Randy Horwitz Attn: Clinic (Dr. Randy Horwitz) 520-626-6484 Arizona Center for Integrative OR Medicine Attn: Dr. Victoria Maizes PO Box 245153 520-626-6484 Tucson, AZ 85724 PLEASE PRINT LEGIBLY Name: Date of Birth: Appointment Date/Time:

Address: City: State, Zip:

Email: Phone: Phone:

Which physician are you seeing? (circle one)

Dr. Randy Horwitz Dr. Victoria Maizes

What are your goals for this visit?

Concerns (please rank by priority) Onset Frequency Severity Example: Headache June 2010 4 times/week mild/mod/severe

Past Medical History Arizona Center for Integrative Medicine Patient Intake Form 2017 2

Have you ever Has a close Conditions Please explain. experienced this? family member? Cancer (type:______) Yes______No______Yes______No______Depression Yes______No______Yes______No______Diabetes Yes______No______Yes______No______Digestive Disorders Yes______No______Yes______No______Heart Disease Yes______No______Yes______No______High Blood Pressure Yes______No______Yes______No______High Cholesterol Yes______No______Yes______No______Lung Disease (asthma, etc.) Yes______No______Yes______No______Liver Disease Yes______No______Yes______No______Seizures Yes______No______Yes______No______Stroke Yes______No______Yes______No______Thyroid Disease Yes______No______Yes______No______Other:______Yes______No______Yes______No______Other: ______Yes______No______Yes______No______Other: ______Yes______No______Yes______No______Other: ______Yes______No______Yes______No______

Do you know if you have ever been exposed to harmful environmental substances?

Please list any medications to which you are allergic:

Medication Reaction/Intolerance

Please list any prescription medications you are taking now.

Please list any supplements, vitamins or herbs you are taking now.

Brand or Other Name (manufacturer) Reason Year Started Dosage Example: St. John’s Wort Feeling Down 2010 3 caps

Have you had any injuries or surgical procedures?

Arizona Center for Integrative Medicine Patient Intake Form 2017 3

What When Comments

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Personal/Social History

Tobacco? Yes No Type and frequency: ______Alcohol? Yes No Estimated drinks per day:______Per Week: ______

Other drugs? Yes No Type and frequency: ______

What is your occupation?

What are your hobbies and interests?

How do you spend your day?

With whom do you live? (include roommates, spouse, children, relatives, pets, etc.)

Name Age Relationship Name Age Relation ship

In what physical activities do you participate?

Activity Frequency Duration Intensity

What do you do to relax?

What are three major stressors in your life?

Do you have a meditation, relaxation, spiritual, reflective, or centering practice that you do?

What gives you a sense of meaning and purpose? If it feels appropriate, describe how spirituality or religion fits into your life, or how it has in the past.

What prior experiences have you had with complementary and alternative medicine?

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Nutrition Diary

Please list all foods and drinks you have consumed in the previous 24 hours. Include meals, snacks, beverages, and condiments.

Is this a typical day? If not, why not?

Do you have any food allergies or intolerances?

Are there any types or groups of food you crave or eat a lot?

Are there any types or groups of food you dislike or rarely eat?

What do you drink on a typical day?

What type of oil do you cook with? What spreads do you add to your food?

How many servings of fruit do you eat/drink each day? Serving = 1 small piece of fruit, ½ cup of juice, ½ cup canned or chopped fruit, ¼ cup dried fruit

How many servings of vegetables do you eat/drink each day? Serving = ½ cup raw or cooked, 1 cup fresh, green leafy vegetables, ¼ cup dried or 1 small piece

Are you currently on a special diet? If so, please describe:

How would you describe your relationship with food?

Do you have any other comments or things you would like to discuss?

Completed by: Date:

If not patient, relationship to patient:

Arizona Center for Integrative Medicine Patient Intake Form 2017